flow of patients into and out of the operating room [46].

Command and control, communication

The city, region, state, and nation should have established plans for disaster management. These plans should be enacted early after a catastrophe and should dictate a means and location for triage, a command center, evacuation plans for casualties, the roles of hospitals in the area, and means of communication. Redundant methods of communication should link all of the above sites [29]. Communication should be maintained between the local burn center and neighboring and national burn centers to coordinate for evacuation and discuss bed availability. Current methods of communication that may be helpful include satellite telephones, international cellular phone, and Internet access. In any given disaster, some of these resources may not be functional.

The American Burn Association (ABA) disaster management plan

Burn care delivered by a burn center remains the optimal treatment plan for any burn victim including victims injured in a mass casualty incident. Currently, the US has 123 burn centers, 56 of which are ABA verified, and approximately 1793 burn beds nationwide [60]. Burn centers are recognized by the US Department of Health and Human Services in legislation outlining the federal response to terrorist acts [42]. Any event that results in more burned victims than the local burn center is organized to manage is defined as a mass casualty burn disaster. Triage from the scene should result in arrival of burn victims from a burn catastrophe within 24 hours of the incident. Under the ABA disaster management plan, each burn center has a defined “surge capacity”, defined as the ability to handle up to 50 % more patients than the maximum number normally listed as capacity. Once surge capacity is reached, individual burn directors should begin triage of burn victims to burn centers with available beds, ideally centers that are ABA verified. This should occur within the first 48 hours after the disaster.

The US disaster response system is tiered so that limits are placed on federal involvement in local affairs during and after a disaster. The levels of response include a local and state response, followed by a civilian Federal response, and finally Military Support to Civil Authorities. The National Disaster Medical System (NDMS), now part of the Department of Health and Human Services (DHHS), is charged with coordinating medical care during Federal disaster response. NDMS functions include medical response to the site, movement of victims from the site to unaffected areas, and assistance with definitive medical care in unaffected areas. An essential component of NDMS’s medical response to the disaster site is Disaster Medical Assistance Teams (DMATs). DMATs are sponsored by a local major medical center, are comprised of 35 personnel each to include physicians, nurses, and administrative staff, and are tasked with providing care during a disaster. In addition, there are 4 Burn Specialty Teams (BSTs) whose role is to augment local capabilities in burn care in the event of a disaster [42]. BSTs provide assistance with acute management to include resuscitation as well as directing triage and transfer of burn victims [42]. The final tier in the national disaster plan incorporates the use of Military Support for Civil Authorities.

Summary

Military operations and civilian mass casualty disasters confront providers with both tragedy and with the potential for strengthening the scientific and organizational foundation of burn care. Table 2 provides a list of advances that occurred following some of the major wars and fire disasters of the last 100 years. These advances were possible not only because of the galvanizing effect of the events, but also because committed multidisciplinary team members worked together to care for patients, to learn from their experiences, and to document those experiences in a disciplined fashion.

ABA, American Burn Association; DOD, Department of

Defense.

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